509A Learning Objectives Week 1 – Flashcards

The kind of information to obtain The order in which to collect the information: see the order of the patterns. This is altered, as needed, dependent on history obtained. How detailed of an assessment is indicated

-FHP list specific items to be assessed -Provide structure for managing the assessment data collected. -Provide the healthcare team with objectives to evaluate and diagnose the health status of individuals, families, and communities. -Promoting Optimum wellness!

1. Health perception-health management 2. Nutritional-Metabolic 3. Elimination 4. Activity/Exercise 5. Sleep/Rest 6. Cognitive/Perceptual 7. Self Perception/Self Concept 8. Role/Relationship 9. Sexuality/Reproductive 10. Coping/Stress Tolerance 11. Value/Belief

How does the individual understand their health and how do they manage their health status? -First pattern assessed -Reason for visit or seeking care -Identifies a person's knowledge of his/her health status and clarifies their understanding of illness, wellness, and treatment. pts understanding of medication, for example -Determines an individual's agreement with and response to treatment modalities. -The Ashline -Discover the need for health education. identifies health-related behaviors and beliefs passed on from family members. -Helps the healthcare team identify available health resources within the individual's community

Includes the processes that maintain energy stores and specific cellular functions. #1 cause of death GLOBALLY is nutrition imbalance (heart attack & stroke related to nutrition) -Inadequacies in this pattern may account for problems in other FHP's. -Fluid intake supports metabolism. Imbalance can occur with age, dehydration, climate variation, illness, and other conditions. ENCOURAGE fluid intake -Nurses will work with both those patients who are underweight and overweight. Either state can contribute to illness and disease. -Skin is the first organ of defense against infection. Nutritional imbalances may increase risks of infection. -Obesity and malnutrition are at epidemic levels in the United States. -Cultural competency in recognizing the impact of culture on nutritional practices.

The focus of this health pattern is on waste removal and excretion. -Input and output measurements assist nurses in determining fluid balance. -Individuals with urinary or fecal incontinence may have symptoms of depression, anxiety, or isolation. -Incontinence can cause skin breakdown and precipitate infection. -30-60% of women will have urinary incontinence -Waste disposal is important to prevent the spread of infection. when changing the bed clean mattress, look for stains, place linens in appropriate containers -Urine and stool are important indicators of health status. look for color, clarity, odor, etc.

This health pattern encompasses three key functions MOBILITY, INDEPENDENT SELF-CARE, and EXERCISE ; LEISURE. -A fifth of the population has some disability that involves mobility or self-care. -Lack of adequate exercise can cause poor muscle tone, balance difficulties, and feelings of fatigue both physically and mentally. -Limited activity increases an individual's risk of certain diseases, injuries, and accidents, including fall risk. -Identifies if community resources are meeting the needs of those with limited mobility. -Nurses must assess and respond to people's ability to perform ADL's (Activities of Daily Living) and IADL's (Independent Activities of Daily Living). be a Guardian of Mobility

Assessment of the person's ability to sleep, rest, and be able to fully function. -Identify sleep disturbances and sleep deprivation. -Sleep deprivation can increase pain, anxiety, and fear. -Sleep deprivation is a major cause of illness and disability in the United States. -Up to 40% of Americans experience insomnia and sleep difficulties (& they are all driving with you!) -Inadequate rest is common in the hospital setting. -Noise and physical space can increase risk of sleep deprivation. -Sleep disturbances can be indicators of pain, stress, and both physical and mental health conditions. -Quality sleep is essential to healing and optimal health and well-being.

Describes an individual's ability to make decisions and gather information from one's environment. Includes both cognition and perception (vision, hearing, smell, taste, touch). This also includes pain. -Pain is the "fifth" vital sign—must be assessed on an ongoing basis. -Pain can interfere with activities of daily living (ADL's), the healing process, mobility, and cognitive functioning -Cognitive functioning affects all levels of nursing care and changes in cognitive functioning must be assessed. Includes all means of perception—seeing, hearing, taste, and touch -Provides nurse with a baseline for education.

Assessment of the individual's understanding and conceptualization of their self as a human being, as well as their level of self-acceptance. This also includes an assessment of their current emotional state. -Includes self-identity, self-worth, self-competency, and body image my judgement as a nurse does not matter, other than making sure pt is reaching personal wellness goals -Feelings and emotions can influence states of wellness and disease, and are often a critical component of nursing care -Feelings of hopelessness, powerlessness, and depression are not uncommon following a loss or disability -Significant disorder can occur when there are self- perception/self-concept issues, such as body dysmorphic disorder.

The roles and relationships that help give the person's life meaning and purpose. This also includes the level of support and responsibility that the person receives and faces as a result of their roles and relationships. -An individual's functional role can be the basis of stress and illness as well as a source of healing and wellness. what is their role? when do they find the time to take care of self? -Loss of relationships can result in grieving, depression, fatigue, and changes in socioeconomic status -Social support can greatly impact the recovery process and quality of one's life.

This pattern focuses on sexual identity, function, reproduction, and sexual satisfaction. -Human sexuality is a key part of human identity and wellness. a lot of different cultural views on sexuality -It is common to have issues and concerns with sexual functioning, and these issues often go unassessed and unaddressed. -Unintended pregnancy and STI (sexually transmitted infections) rates in the United States are the highest in the industrialized world. misinformation -Nurses must be able to provide competent, compassionate nursing care to address the "whole" person, which includes being able to perform a sexual assessment, address sexual concerns, and promote sexual wellness.

The focus of this health pattern is on coping strategies and how individuals manage stress. -An individual's stressors and coping patterns can manifest in specific psychological and physiological illness (acute or chronic), or in long-term patterns of wellness and resiliency. Adequate support systems and resources can be identified to assist individuals both in and outside of the hospital. Nurses are instrumental in assessing coping and stress management patterns and identifying holistic nursing interventions to help people effectively cope and manage their stress.

An individual's ideals and beliefs guide them in decision-making and provide a sense of comfort, meaning, and purpose in life. -An individual's beliefs and values strongly influence how and why they make health care decisions. -Prior knowledge of beliefs may assist nurses in helping individuals achieve their health goals. -More emphasis may be placed on spiritual beliefs and practices when individuals are acutely ill.

Caring section

Universal phenomenon influencing the ways in which people think, feel and behave in relations to one another. Being connected

Concept of care: "Essence and central, unifying, and dominant domain that distinguishes nursing from other health disciplines." Care helps an individual or group improve a human condition. Importance of understanding cultural caring behaviors. What you do and what I do may be different but we will both show we care

Holistic Model Suggests a conscious intention to care promotes healing and wholeness Care before cure Preserves human dignity Nurse-Patient Relationship

Middle Range Theory Developed from perinatal studies Caring is a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment ; responsibility

*Knowing*=Striving to understand an event as it has meaning in the life of the other *Being with*=Being emotionally present to the other *Doing for*=Doing for the other as he or she would do for self if it were at all possible *Enabling*=Facilitating the other's passage through life transitions (e.g., birth, death) and unfamiliar events *Maintaining belief*=Sustaining faith in the other's capacity to get through an event or transition and face a future with meaning

Person to person encounter conveying a closeness and sense of caring. Being there, being with.

Silencing yourself, active listening

A person finds a balance between his or her own life values, goals, and belief systems and those of others

Caring nursing actions that give a patient comfort, dignity, respect, and peace. Ensuring that the patient care environment is clean and pleasant and includes personal items makes the physical environment a place that soothes and heals the mind, body, and spirit

It is important to know the family almost as thoroughly as you know a patient

Develops over time Avoid assumptions What about knowing yourself?

Being honest Advocating Giving clear explanations Keeping family informed Asking permission before proceeding Providing comfort Reading to patient Assurance of nursing services Helping patients do for themselves as they can Teaching family how to keep the patient physically comfortable.

comforting approach to that reaches out to patients to communicate concern and support. Can be: Caring, task-oriented or protective. Contact or non-contact.

Human Interaction, Communication Appreciating individual uniqueness Improving patient & family welfare Mutual give & take Important when assessing patient perceptions of being cared for

Knowledge and caring Caring is user based Knowledge is access based Knowledge is synthesized Relationships of care presence-virtual Managing the Journey

Providing Presence -Being There -Being With Touch -Contact -Non-contact *Listening -Silence yourself -Active listening* Knowing the Patient -Develops over time -Avoid assumptions What about knowing yourself? Spiritual Caring Relieving Pain and Suffering Family Care

Oxygen section

-Neurological -Respiratory -Cardiac All three systems are involved in the process of respiration and oxygen delivery. The pons and medulla oblongata that drive inspiration and expiration are housed in the brainstem. The diaphragm, which is the major respiratory muscle, is innervated by the phrenic nerve. Diseases of the respiratory system, asthma or drug overdose, interfere with the body's ability to for ventilation (the process of inhaling and exhaling). Expiration is dependent on the elastic recoil of the lungs. Perfusion is affected when the heart's ability to adequately pump blood to the system is interfered, as in congestive heart failure, an emboli, or blood loss. Chemical receptors in the aorta stimulate the act of inspiration.

Nasal cannula 24 - 28% l-2 L 30 - 35% 3-4 L 38 - 44% 5-6 L*** Oxymizer 40 - 60 % 2 - 6 L Simple mask 40 - 60% 5-10 L Venturi mask 24 - 50% varies NRB (reservoir) 60 - 100% 6 - 15L Oxygen Hood 28 - 85% 5 - 12 L Oxygen Tent up to 55% 10 -15L